Office of Insurance Regulation Specialty Product Administration FLORIDA COMPANY CODE: FEDERAL EMPLOYER IDENTIFICATION NUMBER: PERIODIC FINANCIAL REPORT FOR (Continuing Care Provider) TO THE OFFICE OF INSURANCE REGULATION OF THE STATE OF FLORIDA Specialty Product Administration 200 East Gaines Street Tallahassee, FL 32399-0331 FOR PERIOD ENDED
GENERAL INFORMATION AND INSTRUCTIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13 Financial statements must be prepared in accordance with generally accepted accounting principles and as prescribed in the Florida Statutes. The Balance Sheet, Statement of Operations and the Statement of Cash flows must be prepared based on yearend amounts. All terms used in this report will have their general meaning except where specific statutory language applies under the applicable provisions of the Florida Insurance Code. This form is submitted electronically. Adobe Reader version 7.0.5 or higher is required. If you do not have that version, please upgrade at http://www.adobe.com prior to downloading any forms. When you downloaded this report, you were assigned a session key. This session key has an expiration date that was also assigned prior to downloading this form. Please make sure you save or submit prior to this expiration date or all work up until the last save will be lost. This session will expire on: Eastern Time To assist you in completing this form click both Highlight Fields and Highlight Required Fields in the upper right hand corner of the report page. This will highlight the fields where you may enter data. The report form will calculate all totals and pre-populate fields based upon your responses. Data cannot be entered into the total and pre-populated fields. Please enter all numeric fields with numbers only (no commas, dashes, dollar signs, etc.). Unanswered questions and blank lines on schedules will not be accepted. If no answers or entries are to be made, enter 0 on all lines asking for a numeric response and "None or "N/A" on all lines requesting a non-numeric response. Additionally, certain Schedules and Exhibits provide the option "Check if N/A if the information requested is not applicable to your company. Line descriptions may not be altered or added. When in doubt where to place an item, show the item in an appropriate Other line and include a supplemental schedule describing the items listed in the Other category. Any item which is of an extraordinary nature should also be entered on an appropriate Other line. Save or Submit buttons are provided on the last page of this report. Hit the ALT+s keys to go to the last page. By clicking the Save button, all data entered on the form will be saved to our website. It is strongly recommended that you save your data periodically as you fill in this form. You will receive a confirmation message once the data is successfully saved. When you either save or submit the form, all data is checked for completeness; you will be notified if errors have occurred. When submitting data, you will be asked to correct these validation errors. Once the form is successfully submitted, the form becomes read-only. To update information after submission, an amended form must be filed through REFS. If additional explanations, supporting statements or schedules are added or are necessary, the additions should be properly cross-referenced to the item being answered. This additional information should be in electronic format (i.e. Word, Excel, PDF, etc) or, if in paper format, scanned in as a PDF, and should be attached and uploaded to the filing as a Miscellaneous Document through REFS. When you have completed a form and selected "Submit Final," your report form is uploaded as a "Completed" document to your Component List; this does not submit the report to the Office of Insurance Regulation. Upon completion of all required items, the "Begin Submission Process" button (bottom right of the screen) will activate. You must select and complete the "Begin Submission Process" to successfully submit your entire filing to OIR. 14. Please print, sign, notarize and upload a PDF version of the Jurat/Attestation Page (see next page) under the corresponding component in REFS. If you do not have a component so named, please upload a signed PDF under the Miscellaneous Documents component. Page 2 of 9
ATTESTATION Please see the Instructions Page OR you may notarize this form electronically by entering the Notary Public, Commission Number and Expiration Date on the form prior to submitting. NOTE: ATTESTATIONS SUBMITTED MANUALLY MUST HAVE ORIGINAL SIGNATURES. COPIES ARE NOT ACCEPTABLE. I. Regardless of the form of the organization, this report must be attested to by the Facility Administrator or Executive Director AND one of the following: A. If you are an individual, the report must be attested to by you. B. If the organization is a corporation, the report must be attested to by one of its corporate officers. C. If the organization is a partnership or unincorporated association, the report must be attested to by the managing general partner. D. If the organization is a trust, the report must be attested to by all trustees and officers. II. As an insurer licensed to transact business in the state of Florida, I am familiar with the laws of Florida relating to continuing care contracts and do hereby certify under penalty of filing false or misleading documents pursuant to 817.2341, FS, or 837.06, FS, that the information reported provided herein is a full and true reporting of the requested information. This report is submitted for compliance with Chapter 651, FS. Print this page (Typed Name) (Typed Name) (Typed Name) (Signature) (Signature) (Signature) (Title) (Title) (Title) Subscribed and sworn to before me This day of, 20 Subscribed and sworn to before me This day of, 20 Subscribed and sworn to before me This day of, 20 Notary Public: Commission Number Expiration Date Personally Known or Produced Identification Notary Public: Commission Number Expiration Date Personally Known or Produced Identification Notary Public: Commission Number Expiration Date Personally Known or Produced Identification (Type of Identification Produced) (Type of Identification Produced) (Type of Identification Produced) Page 3 of 9
SECTION III UNIT ANALYSIS Do not include units permanently utlilzed as something other than the categories below. (A) Currently Sold or Rented (B) Unsold and Available to Market (C) Unsold and Unavailable to Market or Reserved (D) Total (A+B+C) Continuing Care Units 1. Independent Living Units 2. Assisted Living Units 3. Total Continuing Care Units Rental Units 4. Rental Units Skilled Nursing Units 5. Community Beds 6. Sheltered Beds 7. Total Skilled Nursing Units * Other Continuing Care Contracts 8. Independent Living 9. Assisted Living 10. Skilled Nursing 11. Total Other Continuing Care Contracts * Continuing care and continuing care at-home contract holders residing at the location not operated by the provider. Page 4 of 9
BALANCE SHEET ASSETS CURRENT ASSETS 1. Cash 2. Short-Term Investments with Maturity of 12 Months or Less 3. Accounts Receivable 4. Prepaid Expenses 5. Excess of MINIMUM LIQUID RESERVE funds 6. Other 7. TOTAL CURRENT ASSETS NON-CURRENT ASSETS 8. Restricted Assets whose use is limited: a. Required Minimum Liquid Reserve 9. Property, Plant and Equipment a. Less Accumulated Depreciation ( ) 10. Long-Term Investments 11. Other 12. TOTAL NON-CURRENT ASSETS 13. TOTAL ASSETS Page 5 of 9
BALANCE SHEET (continued) LIABILITIES CURRENT LIABILITIES 14. Accounts Payable 15. Accrued Expenses 16. Accrued Interest 17. Refunds Payable 18. Current Portion of Long-Term Debt: a. On Facility 19. Current Portion of Notes Payable 20. Other 21. TOTAL CURRENT LIABILITIES NON-CURRENT LIABILITIES 22. Unearned Entrance Fees 23. Long-Term Debt: a. On Facility 24. Notes Payable 25. Other 26. TOTAL NON-CURRENT LIABILITIES 27. TOTAL LIABILITIES FUND BALANCE 28. Beginning Fund Balance 29. Excess / Deficit (Should equal Line 22, Page 7) 30. Other Contributions or Adjustments 31. TOTAL FUND BALANCE 32. TOTAL LIABILITIES AND FUND BALANCE Page 6 of 9
STATEMENT OF OPERATIONS REVENUES 1. Earned Entrance Fees 2. Health Care Center (Gross) 3. Monthly Maintenance Fees 4. Rental Revenues 5. Other Income (Gross) 6. TOTAL REVENUES EXPENSES 7. Wages and Benefits 8. Food Service 9. Housekeeping 10. Insurance: a. On Facility 11. Interest: a. Long-Term Debt on Facility 12. Leasehold Payments 13. Maintenance 14. Management Fees 15. Marketing 16. Medical Care 17. Taxes: a. Property 18. Other Expenses 19. Amortization 20. Depreciation 21. TOTAL EXPENSES 22. EXCESS / (DEFICIT) Page 7 of 9
STATEMENT OF CASH FLOWS A. OPERATING ACTIVITIES 1. Net Income (From Line 22, Page 7, Statement of Operations) 2. Adjustments to reconcile Net Income to Net Cash provided by operations: a. Gross Entrance Fees Received b. Refunds Paid ( ) c. Earned Entrance Fees ( ) d. e. f. g. h. i. j. k. l. Total Operations Adjustments (Sum of Line 2(a) - Line 2(k)) 3. Total Operating Adjustments (Sum of Line 1 and Line 2(l)) B. INVESTING ACTIVITIES 1. 2. 3. 4. 5. Total Investing Activities C. FINANCING ACTIVITIES 1. Total Gross Debt Principal Paid ( ) 2. 3. 4. 5. 6. Total Financing Activities D. Increase (Decrease) in Cash (Sum of A.3. & B.5. & C.6.) E. Cash at Beginning of Period (Must agree with prior year's ending cash) F. Cash at End of Period (Sum of D & E. Must agree to Line 1, Page 5) Page 8 of 9
SAVE/SUBMIT PAGE Save - Use this button to save your data to our server. It is strongly recommended that you save your data periodically as you fill in this form. You can still save your data even if you have validation errors appear below. Submit Final - Use this button if you have entered all the required information and want to submit this data to our server. If you have validation errors, they must be corrected before being able to submit the form data. Once you successfully submit the form data, you can no longer make changes. The session key will expire on: Save Eastern Time Submit Final Page 9 of 9